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Based on observations made on October 4, 2010, the facility failed to maintain the fire and smoke resistance rating of interior walls and ceilings.

The findings include:

1. A portion of the lower wall assembly in the oxygen storage and manifold room had been damaged as observed at 10:10 a.m. on October 4, 2010. The wall was no longer intact in this room.

2. The data and communications room off of central supply was examined at 10:58 a.m. on October 4, 2010.

a) An open faced three inch conduit was being used a pass through for large amounts of blue communication wire in the upper portion of one wall. This conduit was not sealed.

b) An open hole midway in a wall was being used as a pass through for three blue wires and one white wire. This hole was not sealed.

3. The hazardous waste room was examined at 1:20 p.m. on October 4, 2010. Two of the ceiling tiles in this room had been removed for wire installation. At the time of the observation the contractor was not on-site and the ceiling tiles must be replaced during these interim periods to maintain the fire rating of the assembly.

4. The mechanical room next to the hazardous waste room was examined at 1:22 p.m. on October 4, 2010. A ceiling tile was missing from the ceiling assembly.

Based on observations made on October 4, 2010, the facility failed to assure that there was no impediment to closing a corridor door.

The findings include:

The swinging door to the temporary darkroom was exercised at 10:37 a.m. on October 4, 2010. The door did not close and latch on three attempts to the inactive leaf on the door frame due to resistance of the seal material put on the door to prevent light from accessing the room.

Based on observations made on October 4, 2010, the facility failed to prevent a corridor door to a hazardous area from being held open by means other than those specified in 7.2.1.8.2 of the Life Safety Code a follows: In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code?.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

The findings include:

The corridor door to the central supply room on the kitchen corridor was held open by a rubber chock as observed at 1:25 p.m. on October 4, 2010. The room was vacant at the time of the observation. Rubber chocks are not an acceptable means of holding this door open.

Based on observations made on October 4, 2010, the facility failed to maintain the fire resistance rating of smoke barriers.

The findings include:

1. The smoke barrier wall above the set of corridor doors between the nurse's station area and the Emergency Room corridor was examined at 1:45 p.m. on October 4, 2010. Two open holes serving as pass through for bundles of blue communication wire and for blue, yellow and white wires were not sealed to maintain the fire rating of the smoke barrier.

2. The smoke barrier wall above the set of corridor doors by room 2 was examined at 1:50 p.m. on October 4, 2010. Three openings serving as pass through for bundles of wire were not sealed to maintain the fire rating of the smoke barrier.

3. The smoke barrier wall above room 1 was examined at 1:57 p.m. on October 4, 2010. Open penetrations around four conduit were not sealed to maintain the fire rating of the smoke barrier.

Based on observations made on October 4, 2010, the facility failed to assure that smoke barrier doors closed tightly to resist the passage of smoke.

The findings include:

1. The set of smoke barrier doors from the Operating Room corridor to the corridor by the laundry was exercised at 10:33 a.m. on October 4, 2010. The latching hardware on the north door of this set did not function properly to allow the door to close flush with the adjoining door to resist the passage of smoke.

2. The set of smoke barrier doors by room 23 were exercised at 12:32 p.m. on October 4, 2010. The door adjacent to room 23 was binding with the top of the door frame and preventing it from closing flush with the meeting edge of the other door to prevent the passage of smoke.

Based on observations made on October 4, 2010, the facility failed to assure that the door protecting a storage room greater than 50 square feet in size had a self-closure device on the door.

The findings include:

The Pharmacy storage room off of the Emergency Room corridor was measured at 10:22 a.m. on October 4, 2010. The room was approximately 9 feet by 14 feet in size (126 square feet). The door to this room did not have a self-closing mechanism on it.

Based on observations and discussion with the maintenance staff member A on October 4, 2010, the facility failed to assure that a means of egress was readily accessible at all times.

The findings include:

No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof per section 7.1.10.2.1 of the Life Safety Code.

The exterior exit door by room 17 was examined at 12:55 p.m. on October 4, 2010. A printed sign stating "This door is broken. Do not use this door" was posted on the door. In discussions with the maintenance staff member A at the time of the observation it was determined that the sign was posted to prevent a wandering patient from using the door. The sign itself had the potential to confuse other occupants as to the accessibility of using the exit door during an emergency. Note: The sign was removed from the door after the observation was made and confirmed by the surveyor while on-site.

Based on review of the battery-powered emergency light testing logs and in discussions with them maintenance staff member A on October 4, 2010, the facility failed to perform an annual test on one of the light fixtures.

The findings include:

One or more battery-powered emergency lighting units shall be provided in any Anesthetizing location per section 3-3.2.1.2(a)5e of NFPA 99, 1999 edition and 517-63 of NFPA 70, 1999 edition. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours per section 7.9.3 of the Life Safety Code . Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

The testing logs for the battery-powered emergency light in the Operating Room was reviewed at the facility on October 4, 2010. The monthly checks for the light were current. No written documentation was available that the light had had an annual test performed on it and this was confirmed in discussions with the maintenance staff member A during the review.

Based on review of the fire drill reports on October 4, 2010, the facility failed to assure that fire drills were held at least quarterly on each shift.

The findings include:

The fire drill reports were reviewed at the facility on October 4, 2010. No written documentation was provided that fire drills were conducted on:

a) The 11 p.m. to 7 a.m. shift during the fourth quarter (October, November, December) of 2009.

b) The 3 p.m. to 11 p.m. shift during the first quarter (January, February, March) of 2010.

Based on observations made on October 4, 2010, the facility failed to maintain the automatic sprinkler system in accordance with the standards of NFPA 13, 1999 edition.

The findings include:

Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per section 3-2.7.2 of NFPA 13 (1999 edition).

An escutcheon was missing from a sprinkler in room 18 as observed at 12:49 p.m. on October 4, 2010.

Based on review of the automatic sprinkler system inspection reports on October 4, 2010, the facility failed to assure that the water supply to the building was capable of providing continuous and automatic pressures to meet the demands of the sprinkler system should it activate.

The findings include:

The minimum residual pressure required for a sprinkler pipe schedule system shall be 15 psi for light hazard occupancies and 20 psi for ordinary hazard occupancies per section 7-2.2.4 of NFPA 13, 1999 edition. The minimum water supply requirements for a hydraulically designed sprinkler system shall be determined by adding the hose stream demand to the water supply for sprinklers per section 7-2.3.1.1 of NFPA 13 and listed on the placard at the riser per section 10.5 of NFPA 13.

The sprinkler report of May 19, 2010 was reviewed at the facility on October 4, 2010. The report notes "The residual water pressure to the building is 50 psi. However the residual pressures for both wet systems are system #1 - 10 psi and system #2 - 25 psi. The residual pressure should be equal to the water source supplying the building. This needs to be looked into". The gauges that the readings were taken from were new as of January 17, 2010. The residual reading for system #1 falls below the minimum 15 psi for light hazard occupancies. There was no reading for a hydraulic system. The system must be inspected for any obstruction or impediment that could contribute to the decrease in residual water pressure.

Based on observations made on October 4, 2010, the facility failed to ensure that baffle hood filters located in the kitchen hood were installed in accordance with the standards of NFPA 96, 1998 edition and in accordance with UL 1046 listings.

The findings include:

Grease filters shall be installed at an angle not less than 45 degrees from the horizontal per section 3-2.5 of NFPA 96. Grease filters that require a specific orientation to drain grease shall be clearly so designated, or the hood shall be constructed so that filters cannot be installed in the wrong orientation per section 3-2.7 of NFPA 96. Baffle filters installed in backshelf canopies shall be in the vertical position to assure that the self-draining filter drains into a pitched full length grease trough per UL 1046 listing.

The kitchen range hood was examined at 1:16 p.m. on October 4, 2010. Seven of the eight baffle hood filters over the kitchen range had been installed in the horizontal position, with one being in the vertical position. Those baffles in the horizontal position were incapable of self-draining into the grease trough.

Based on observations made on October 4, 2010, the facility failed to maintain the means of egress, including exit corridors, free from obstructions that would interfere with their instant use in case of fire or other emergency and also failed to prevent the means of egress from being used for storage purposes.

The findings include:

In accordance with Centers for Medicare and Medicaid Services (CMS) Survey and Certification letters S&C-04-41 and S&C-10-18 items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery items and other similar items must be stored properly or removed from the corridor.

1. Delivered items including materials for the on-going construction phase of the building were initially observed to be stored in the exit corridor adjacent to the laundry room at 9:50 a.m. on October 4, 2010. These items were stored in the same location as observed again at 12:10 p.m. on October 4, 2010. This period of time exceeded the 30 minutes allowed by CMS. Note: The items had been removed by 2:25 p.m. on October 4, 2010 when the fire alarm system was activated and the exit corridor checked by the surveyor while on-site.

2. Two folded wheelchairs were stored in the exit corridor opposite the Maintenance office as observed initially at 10:00 a.m. on October 4, 2010. The wheelchairs were in the same location as observed again at 12:10 p.m. and 2:25 p.m. on October 4, 2010. This period of time exceeded the 30 minutes allowed by CMS.

3. A medical machine was stored in the corridor outside of the temporary darkroom as observed initially at 10:38 a.m. on October 4, 2010. The medical machine was in the same location as observed at 2:25 p.m. on October 4, 2010. This period of time exceeded the 30 minutes allowed by CMS.

Based on observations made on October 4, 2010, the facility failed to assure that a portable LPG tank attached to a barbecue was located an appropriate distance from any building openings.

The findings include:

Portable liquid petroleum gas (LPG) tanks used for such items as barbecues shall be located at least 3 feet from any building opening and at least 5 feet in any direction from an exterior source of ignition, direct-vent appliances or mechanical ventilation air intakes per section 3-2.2.2 of NFPA 58, 1998 edition.

A portable barbecue with a propane LPG tank in the patio area adjacent to the activity room was stored within 3 feet of the window opening into the activity room as observed at 1:10 p.m. on October 4, 2010.

Based on observations made on October 4, 2010, the facility failed to properly designate the branch functions of each automatic transfer switch.

The findings include:

Type I essential electrical systems are comprised of two separate systems, being the emergency system and the equipment system per section 3-4.2.2.1 of NFPA 99, 1999 edition. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).

The two transfer switches in the combination generator and electrical room were examined at 9:02 a.m. on October 4, 2010. One switch was marked ATS-1 and the other marked ATS-2. There was no designation on either transfer switch denoting whether that particular switch served the emergency (life safety and critical functions) branch, the equipment branch or if the systems had been further isolated into separate Life Safety and Critical branches.

Based on observations made on October 4, 2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition, NFPA 99, 1999 edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

1. Panel boards located in the combination generator and electrical room were examined between 8:55 a.m. and 8:59 a.m. on October 4, 2010. Several of the panel boards had incomplete service listings for the breakers. These included:
a) Panel board LAE1 did not have a service listing for breakers 7, 9, 11, 21, 25, 29, 31, 33 and 35.
b) Panel board LXE-1 did not have a service listing for breakers 2, 4, 13, 15, 18, 20, 22, 24, 26, 30, 32, 34 and 39.
c) Panel board LAE-3 did not have a service listing for breakers 18, 20, 22 and 29.
d) Panel board LLE-1 did not have a service listing for breakers 2, 6, 10, 11, 13, 15, 17, 25, 26, 27, 28, 29 and 30.
e) Panel board L1 did not have a service listing for breakers 23, 25, 26, 27 and 28.

The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to the power strip.

2. A refrigerator in the Radiology office was plugged into a power strip as observed at 11:10 a.m. on October 4, 2010.